Approach To Suspected Diabetes Mellitus Definitions

Type I diabetes Caused by what is believed to be an autoimmune destruction of the pancreatic beta cells and complete loss of endogenous insulin production. The presentation of this type of diabetes usually is acute, with hyperglycemia and metabolic acidosis. These patients are dependent upon exogenous insulin delivery. Type 2 diabetes Heterogenous syndrome of insulin resistance caused by genetic factors and or obesity and relative insulin deficiency. Oral medications to enhance endogenous...

Approach To Suspected Lyme Disease

The evaluation of the patient who presents with fever and a rash is a very common problem that often frustrates and confuses beginning clinicians, partly because of their unfamiliarity with many typical rash patterns, and partly because the rash may be an incidental nonspecific finding (as in miliaria or heat rash), may be a sign of serious, even fatal illness (as in the purpuric rash of meningococcemia), or may be the pathognomonic finding that yields the diagnosis, as in the case of the...

Approach To Painless Jaundice Definitions

Cholestasis Deficient bile flow that can result from intrahepatic disease or extrahepatic obstruction. Conjugated bilirubin (direct-reacting bilirubin) Bilirubin that has entered the liver and been enzymatically bound to glucuronic acid forming bilirubin monoglucuronide or diglucuronide. Jaundice or icterus Yellowing of the skin or whites of the eyes, indicating hyperbilirubinemia. Unconjugated bilirubin (indirect-reacting bilirubin) Bilirubin that has not been enzymatically bound to glucuronic...

Clinical Pearls For Diagnosis Of Exclusion

Fistulas are common with Crohn disease because of its transmural nature but are uncommon in ulcerative colitis. 16.2 C. Pancolitis has the highest risk of malignancy in ulcerative colitis. 16.3 C. With toxic megacolon, antibiotics and surgical intervention are often necessary. 16.4 B. Irritable bowel syndrome is characterized by intermittent diarrhea and crampy abdominal pain, but no weight loss or abnormal blood in the stool. It is a diagnosis of exclusion once other conditions, such...

Answers

Hashimoto thyroiditis is the most common cause of hypothyroidism with goiter in the United States. It is most commonly found in middle-aged women, although it can be seen in all age groups. Patients can present with a rubbery, nontender goiter that may have scalloped borders. Iodine deficiency is exceedingly uncommon in the United States because of iodized salt. Graves disease is a hyperthyroid condition. Patients with multinodular goiter usually are euthyroid. Patients with thyroid...

References

Insulin therapy for diabetic ketoacidosis bolus vs. continuous insulin infusion. Diabetes Care 1995 18 1187. Delaney MF. Diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome. Endocrinol Metab Clin North Am 2000 129 683-705. Fass B. Diabetic ketoacidosis and hyperosmolar coma. In Norman Lavin, ed. Manual of endocrinology and metabolism, 2nd ed. Boston Little Brown, 1994 543-562. Fishbein HA, Palumbo PJ. Acute metabolic complications in...

Epidemiology

Sickle cell anemia is the most common autosomal recessive disorder and the most common cause of hemolytic anemia in African Americans. Approximately 8 of African Americans carry the gene (i.e., sickle cell trait), with one in 625 affected by the disease. Complications of Sickle Cell Disease Acute painful episodes, also known as pain crisis, are a consequence of microvascular occlusion of bones by sickled cells. The most common sites are the long bones of the arms, legs, vertebral column, and...

Clinical Approach

Syphilis is classically called the great imitator for its protean manifestations. After a decline in cases over the prior decades, the incidence of syphilis has been increasing since the 1980s. The public health consequences can be grave, so recognizing and correctly treating this disease is of great importance. An estimated 70,000 new cases of syphilis occur every year in the United States. Most occur in young adults in their twenties, and most cases are concentrated in the southern states....

Answers To Case 43 Diabetic Ketoacidosis

Summary A young woman presents with unintentional weight loss, nocturia, and polyuria, with hyperglycemia that likely represents new-onset diabetes mellitus. She is hypovolemic as a result of osmotic diuresis and has an anion gap metabolic acidosis, which is primarily caused by ketoacids. Her mental status and abdominal pain probably are manifestations of the metabolic acidosis and hyperosmolarity. Most likely diagnosis Diabetic ketoacidosis (DKA). Next step Aggressive hydration to improve her...

Alcohol Withdrawal

Tremulousness Earliest symptom occurring within 6 hours of abstinence, caused by CNS and sympathetic hyperactivity, often referred to as the shakes or jitters, and can occur even when patients still have a significant blood alcohol level. In addition to the typical 6- to 8-Hz tremor, which can be violent or subtle, insomnia, anxiety, gastrointestinal upset, diaphoresis, and palpitations can occur. Tremor typically diminishes over 48-72 hours, but anxiety, easy startling, and other symptoms can...

Approach To Suspected Endocarditis

Infectious endocarditis refers to a microbial process of the endocardium, usually involving the heart valves. The clinical presentation depends upon the valves involved (left-sided versus right-sided), as well as the virulence of the organism. Highly virulent species, such as Staphylococcus aureus, produce acute infection, and less virulent organisms, such as the viridans group of streptococci, tend to produce a more subacute illness, which may evolve over weeks. Fever is present in 95 of all...

Cost

Supplements patient's own insulin production Must check blood glucose frequently to monitor therapy and prevent complications Augments patient's own insulin production, works at the pancreatic beta cells Can cause hypoglycemia can accumulate in renal insufficiency and cause prolonged hypoglycemia. Best for young patients with fasting plasma glucose < 300 mg dL gluconeogenesis in the liver decreases insulin resistance In patients with renal insufficiency or liver dysfunction may cause lactic...

Info

Short-acting inhaled 3,-agonist, as needed oral steroids may be required includes lifestyle modification along with medical therapy. Recommendations include a high-protein, low-fat diet, antireflux diet for 3-4 weeks elevation of the head of the bed consumption of the last meal of the day at least 3 hours before bedtime avoidance of caffeine, alcohol, peppermint, and chocolate smoking cessation and weight reduction. If the cough does not resolve with lifestyle changes, daily treatment with an...

Clinical Pearl

The history is the single most important tool in obtaining a diagnosis. All physical findings, laboratory and imaging studies are first obtained, and then interpreted, in the light of the pertinent history. a. Age. gender, and ethnicity must be recorded because some conditions are more common at certain ages for instance, pain on defecation and rectal bleeding in a 20-year-old may indicate inflammatory bowel disease, whereas the same symptoms in a 60-year-old would more likely suggest colon...

Bleeding

A careful history is the most effective way to determine the presence and significance of a bleeding disorder. Abnormal hemostasis may result from liver disease, uremia, malignancy, or systemic lupus erythematous. The history should include medications, including over-the-counter products (aspirin), family history of abnormal bleeding, epistaxis, menorrhagia, excessive prolonged bleeding from minor cuts, bruising, prolonged or profuse bleeding after dental extraction, excessive bleeding after...

Criteria For Diagnosis Of Diabetes Mellitus

Symptoms of diabetes plus casual glucose concentration > 200 mg dL (11.1 mmol L). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydispsia, and unexplained weight loss. 2. FPG > 126 mg dL (7.0 mmol L). Fasting is defined as no caloric intake for at least 8 hours. 3. 2hPG > 200 mg dL during an OGTT. The test should be performed as described by WHO, using a glucose load containing the equivalent of 75-g...

Approach To Acute Renal Failure Definitions

Acute renal failure (ARF) Abrupt decline in glomerular filtration rate (GFR). True GFR is difficult to measure, so we rely on increases in serum creatinine levels to indicate a fall in GFR. Because creatinine is both filtered and secreted by the kidneys, changes in serum creatinine concentrations always lag behind and underestimate the decline in the GFR. In other words, by the time the serum creatinine level rises, the GFR has already fallen significantly. Anuria Less than 50 mL of urine...

Clinical Pearls

Bone mineral density screening should be offered to patients with risk factors for osteoporosis and to all women older than 65 years. Every 1 standard deviation (SD) decrease in bone mineral density below the mean of young adults doubles the fracture risk. Osteoporosis is defined as a T score of -2.5 SD. Patients with osteoporosis should have normal serum calcium, phosphorus, and alkaline phosphatase levels. Laboratory abnormalities should prompt a search for an alternative diagnosis. Fractures...

Associated Conditions

Intravascular catheter, intravenous drug use (tricuspid valve endocarditis) 30-35 of early prosthetic valve infection Previous genitourinary tract disease or instrumentation Elderly patients, often with underlying GI mucosal lesion, e.g., adenoma or malignancy Intravascular catheters, intravenous drug use actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae). The clinical features, blood cultures, and echocardiography are used to diagnose cases of endocarditis...

Considerations

The approach to health maintenance consists of three parts (a) cancer screening, (b) immunizations, and (c) addressing common diseases for the particular patient group. For a 66-year-old woman, this includes annual mammography for breast cancer screening, colon cancer (annual stool for occult blood and either periodic colonoscopy or barium enema), tetanus booster every 10 years, pneumococcal vaccine, and yearly influenza immunization. Screening for hypercholesterolemia every 5 years up to age...

Answers To Case 4 Peptic Ulcer Disease

Summary A 37-year-old man presents with complaints of chronic and recurrent upper abdominal pain with characteristics suggestive of duodenal ulcer the pain is burning, occurs when the stomach is empty, and is relieved within minutes by food or antacids. He does not have evidence of gastrointestinal bleeding or anemia. He does not take nonsteroidal antiinflammatory drugs, which might cause ulcer formation, but he does have serologic evidence of H. pylori infection. Most likely diagnosis Peptic...

Treatment

Treatment options can be categorized in terms of primary and secondary therapy based on different management goals. Primary therapy consists of clot dissolution or thrombolysis or removal of clot by surgical embolectomy and usually is reserved for patients with a high risk for adverse outcomes if the clot remains, that is. those with right-heart failure or hypotension. When right-heart function remains normal, patients typically have good outcomes with anticoagulation as secondary therapy....

Medical Causes Of Delirium

Discrete CNS lesion present Head injury stroke or intracranial bleed Infection meningitis, meningoencephalitis, brain abscess Mass lesion hematoma, tumor Seizure, postictal No discrete CNS lesion Metabolic encephalopathy Anoxia any cause, heart or respiratory failure, pulmonary embolus, sleep apnea, etc. Hepatic encephalopathy Uremic encephalopathy Hypo- hyperglycemia Hyponatremia hypercalcemia Hypo- hyperthermia Drug withdrawal, especially alcohol and benzodiazepines, but also demerol and many...

Objectives

Know the natural history and the clinical and radiographic manifestations of primary and reactivation pulmonary TB and of latent TB infection. 2. Understand the methods of diagnosis of TB. 3. Learn treatment strategies for TB. 4. Know the common extrapulmonary sites of TB. including pleurisy, lymphadenitis, miliary, meningeal, genitourinary, skeletal, and adrenal TB. This elderly Asian gentleman has symptoms suggestive of TB. such as weight loss and productive cough. A chest radiograph is...

Adverse Effects

Volume overload, electrolyte disturbances Hypophosphatemia, hypomag-nesemia, hypocalcemia, fever Efficacy short-lived (tachyphylaxis) Glucocorticoids (effective in cancer-induced hypercalcemia) Hyperglycemia, osteoporosis, immune suppression Dialysis (renal Acute (hours) Volume shifts, electrolyte dis- insufficiency) orders, complicated procedure Dialysis (renal Acute (hours) Volume shifts, electrolyte dis- insufficiency) orders, complicated procedure intoxication with vitamin A, vitamin D. or...

Atn

Isosthenuric with muddy brown granular casts Moderate to severe proteinuria with red blood cells and red blood cell Mild to moderate proteinuria with red and white blood cells and white blood cell casts < 20 mEq L (early) > 20 mEq L (later) urinalysis usually reveals a high specific gravity and normal microscopic findings. Individuals with postrenal failure typically arc unable to concentrate the urine, so the urine osmolality is equal to the serum osmolality (isosthenuria) and the specific...

Approach To Peripheral Vascular Disease Definitions

Ankle-brachial index (ABI) Ratio of ankle to brachial systolic blood pressure determined using Doppler ultrasound flow. Claudication syndrome Calf pain that increases with walking or leg exertion in a predictable manner and resolves with rest. Although atherosclerosis is a systemic disease, clinicians often focus on the coronary circulation and are less attentive to the extremities. Yet atherosclerotic peripheral arterial disease (PAD) is estimated to affect up to 16 of Americans 55 years and...

Approach To Syncope

Syncope is a transient loss of consciousness and postural tone with subsequent spontaneous recovery. It is a very common phenomenon, resulting in 5-10 of emergency room visits and resulting hospitalization. The causes are varied, but they all result in transiently diminished cerebral perfusion leading to loss of consciousness. The prognosis is quite varied, ranging from a benign episode in an otherwise young, healthy person with a clear precipitating event, such as emotional stress, to a more...

Case

A 26-year-old woman presents to the emergency room complaining of sudden onset of palpitations and severe shortness of breath and coughing. She reports that she has experienced several episodes of palpitations in the past, often lasting a day or two, but never with dyspnea like this. She has a history of rheumatic fever at age 14 years. She is now is 20 weeks pregnant with her first child and takes prenatal vitamins. She denies use of any other medications, tobacco, alcohol, or illicit drugs....

Can Haemoptysis Cause Asphyxiation By Filling Up Alveolar Airs Spaces

Horner syndrome Symptoms are ptosis, loss of pupillary dilation (miosis), and loss of sweating on the same side of the face (anhydrosis) caused by compression of the superior cervical ganglion. Superior vena cava syndrome Obstruction of venous drainage leads to dilation of collateral veins of the upper part of the chest and neck, edema of the face, neck and upper part of the torso, shortness of breath, and central nervous system (CNS) symptoms, such as confusion, headache, and visual problems....

The Nephritic Syndrome

The presentation of acute renal failure with associated hypertension, hematuria, and edema is consistent with acute GN. Acute renal failure, as manifested by a decrease in urine output and azotemia, results from impaired urine production and ineffective filtration of nitrogenous waste by the glomerulus, respectively. The glomerular apparatus (endothelial and epithelial components) is responsible for the ultrafiltration of blood in the kidney and the initial formation of what will later become...

Approach To Suspected Diabetic Ketoacidosis

DKA is a clinical syndrome that results when the triad of anion gap metabolic acidosis, hyperglycemia, and ketosis is present and is caused by a significant insulin deficiency. It is a medical emergency, with an overall mortality rate < 5 if patients receive prompt and appropriate medical treatment. The majority of episodes are preventable, and many of the deaths also are preventable with proper attention to detail during management. In the normal physiologic state, there is a fine balance...

Approach To Hyperlipidemia

Atherosclerotic coronary artery disease is the leading cause of death of both men and women in the United States. Because of the association of hypercholesterolemia and development of atherosclerotic heart disease, most authorities recommend routine screening of average risk individuals at least every 5 years. Clinical laboratories usually measure total cholesterol, HDL, and triglycerides. The LDL cholesterol may be calculated by using the formula LDL Total cholesterol - HDL - (Triglycerides 5)...

Approach To Dementia

Dementia Impairment of memory and at least one other cognitive function (e.g., language, visuospatial orientation, judgment) without alteration in consciousness, representing a decline from previous level of ability and interfering with daily functioning and independent living. Alzheimer disease Leading cause of dementia, accounting for half of the cases involving elderly individuals, correlating to diffuse cortical atrophy and hippocampal atrophy with ventricular enlargement. The pathologic...

Answers To Case 7 HIV and Pneumocystis Carinii Pneumonia

Summary A 32-year-old man with known HIV infection but unknown CD4 count presents with subacute onset of fever, dry cough, and gradually worsening dyspnea. He is not undergoing any antiretroviral therapy or taking prophylactic medications. Diffuse bilateral pulmonary infiltrate is seen on chest x-ray. and he is tachypneic and hypoxemic. The presence of oral thrush suggests that he is immunosuppressed. His leukocyte count is decreased, and his LDH level is elevated. Most likely diagnosis...

Red Flags For Secondary Headache Disorders

Fundamental change or progression in headache pattern First severe and or worst headache Abrupt-onset attacks, including those awakening one from sleep Abnormal physical examination findings (general or neurologic) Neurologic symptoms lasting > 1 hour New headache in individuals aged < 5 years or > 50 years New headache in patients with cancer, immunosuppression, pregnancy Headache associated with alteration in or loss of consciousness Headache triggered by exertion, sexual activity, or...

Approach To Suspected Mi

Acute coronary syndrome Spectrum of acute cardiac ischemia ranging from unstable angina (ischemic pain at rest or at lower threshold of exertion or new onset of chest pain) to acute MI (death of cardiac tissue), usually precipitated by thrombus formation in a coronary artery with an atherosclerotic plaque. Acute myocardial infarction Death of myocardial tissue because of inadequate blood flow. Non-ST elevation myocardial infarction (NSTEMI) MI. but without ST elevation as defined below. May...

Monitoring

HMG-CoA reductase inhibitors (statins) Lower LDL 25-55 Lower TG 10-25 Raise HDL 5-10 Lower TG 25-35 Lower LDL 15-25 Raise HDL 15-30 Bile acid resins (e.g cholestyramine) Fibric acid derivatives (e.g gemfibrozil) LFT liver function test TG triglycerides. From Rader DJ. Hobbs HH. Disorders of lipoprotein metabolism. In Braunwald E, Fauci AS. Kasper KL. ct al. eds. Harrison's principles of internal medicine, 16th ed. New York McGraw-Hill. 2005 2296. LFT liver function test TG triglycerides. From...

Answers To Case 25 Iron Deficiency Anemia

Summary A healthy 52-year-old man complains of a 4- to 5-month history of increasing exercise intolerance, but he denies orthopnea, PND. edema, or other signs of heart failure. The patient uses an nonsteroidal antiinflammatory drug (NSAID) regularly. He has not had any overt gastrointestinal (GI) blood loss. On examination, he weighs 205 lb, and he has slight pallor of the conjunctiva, skin, and palms. He is anemic, with a hemoglobin level of 8.2 g dL. Most likely diagnosis Iron-deficiency...

Classification Of Glomerulonephritis Based On Clinical Presentation

Primary renal disorders (based on histopathology) Membranoproliferative glomerulonephritis (MPGN, types I and II) Mesangioproliferative glomerulonephritis (MSGN) Crescentic glomerulonephritis Immune deposit (anti-GBM) Pauci-immune (ANCA) Fibrillary glomerulonephritis Proliferative glomerulonephritis (IgA nephropathy) Secondary renal disorders (based on clinical presentation) Lupus nephritis Postinfectious glomerulonephritis (poststreptococcal GN) Hepatitis C hepatitis B-related...

Etiologies Of Rhabdomyolysis

Drug abuse (cocaine, amphetamines, LSD, heroin, phencyclidine) Medications (diuretics, narcotics, theophylline, corticosteroids, benzodiazepines, phenothiazides, tricyclic antidepressants) Trauma High temperatures Heat stroke Strenuous exercise Seizures Toxin ingestion Infection renal failure and possible multiorgan failure. One key finding is urine dipstick showing blood but urine microscopy not identifying red blood cells. Serum markers, such as creatinine kinase, then can be measured. The...

Approach To Colitis

The differential diagnosis for colitis includes ischemic colitis, infectious colitis (C. difficile. E. coli, Salmonella, Shigella, Campylobacter), radiation colitis, and IBD (Crohn disease versus ulcerative colitis). Mesenteric ischemia usually is encountered in people older than 50 years with known atherosclerotic vascular disease or other cause of hypoperfusion. The pain usually is acute in onset following a meal and not associated with fevers. With an infectious etiology, patients often have...

Pleural Fluid Appearance

Clear yellow Transudative, e.g., secondary to CHF. cirrhosis, nephrotic syndrome Frank pus Infectious process, empyema Bloody If the hematocrit of the pleural fluid is < 1 Blood caused by traumatic tap 1-20 Cancer, pulmonary embolus, tuberculosis > 50 Hemothorax, most commonly secondary to trauma but also seen in malignancy and pulmonary embolism Milky, turbid Chylothorax triglycerides > 110 mg dL resulting from disruption of thoracic duct, cholesterol effusion To appreciate the...

Comprehension Questions

29.1 An 18-year-old with a 1-week history of fever, headache, increasing confusion, and lethargy presents to the emergency room. His physical examination is normal, and he has no focal neurologic signs. CT scan of his head is negative. An LP reveals a WBC count of 250 mm with 78 lymphocytes and 500 red blood cells (RBCsVmm-1 in tube 1 and 630 mm3 in tube 2. No organisms are seen on Gram stain. Which of the following is the best next step A. Intravenous ceftriaxone, acyclovir, and vancomycin D....

Ranson Critieria For Severity Of Pancreatitis

Age > 55 years WBC > 16.000 mm' Serum glucose > 200 Serum lactate dehydrogenase (LDH) > 350 IU L AST > 250 IU L Within 48 hours of admission Hematocrit drop > 10 points Blood urea nitrogen (BUN) rise > 5 mg dL after intravenous hydration Estimated fluid sequestration of > 6 L Source Ranson JH. Etiological and prognostic factors in human acute pancreatitis A review. Am J Gastroenterol 1982 77 633. processes, but in the United States, alcohol use is the most common cause, and...

Nyha Functional Classification

Class I No limitation during ordinary physical activity. Class II Slight limitation of physical activity. Develops fatigue or dyspnea with moderate exertion. Class III Marked limitation of physical activity. Even light activity produces symptoms. Class IV Symptoms at rest. Any activity causes worsening. low oxygen consumption during exercise have an annual mortality rate of 20 in class IV. the rate is 60 annually. Patients with a low ejection fraction (LVEF < 20 ) also have very high...

Secondary Causes Of Hypertension

Parenchymal (glomerulonephritis, polycystic renal disease, diabetic nephropathy) Renovascular Primary aldosteronism Cushing syndrome Pheochromocytoma Hyperthyroidism Growth homione excess (acromegaly) Oral contraceptives Increased intravascular volume (posttransfusion) Hypercalcemia Medications (sympathomimetics, glucocorticoids) smoking, dyslipidemia, diabetes mellitus, obesity, kidney disease, and a family history of premature cardiovascular disease. Target organ damage of hypertension...

Basic Tests For Initial Evaluation Of Hypertension

Urine for protein, blood, glucose, and microscopic examination Hemoglobin or hematocrit leukocyte count Serum creatinine or blood urea nitrogen Total. HDL. and LDL cholesterol triglycerides Electrocardiogram Consider thyroid-stimulating hormone abdomen for enlarged kidneys, masses, or an enlarged abdominal aorta, evaluation of the lower extremities for edema and perfusion, and a neurologic examination should be standard. Some initial laboratory testing is also indicated (Table 9-3). Counseling...

Pathophysiology

When venous thrombi dislodge from their site of formation, they may embolize to the pulmonary arteries causing PE. The deep proximal lower-extremity veins are the most common site of clot formation resulting in PE. although thromboses in pelvic, calf, and upper-extremity veins may also embolize. Obstruction to the pulmonary artery causes platelets to release vasoactive agents such as serotonin, thereby elevating pulmonary vascular resistance. The resulting increase in alveolar dead space and...

Hypercalcemia Harrison

Hypercalcemia And Diagnostic Algorithm

Bolser DC, et al. Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines. Chest 2 X 6 129 I Suppl IS-23S. Irwin RS, Madison JM. The diagnosis and treatment of cough. N Engl J Med 2000 343 1715-1721. Morice AH. Kastelik JA. Chronic cough in adults. Thorax 2003 58 901-907. Williams SG. Schmidt DK. Redd SC. et al. National Asthma Education and Prevention Program. Key clinical activities for quality asthma care. Recommendations of...

Approach To Suspected Cardiac Tamponade

Cardiac tamponade refers to increased pressure within the pericardial space caused by an accumulating effusion, which compresses the heart and impedes diastolic filling. Because the heart can only pump out during systole what it receives during diastole, severe restrictions of diastolic filling lead to a marked decrease in cardiac output, which can cause cardiovascular collapse and death. If pericardial fluid accumulates slowly, the sac may dilate and hold up to 2000 mL producing amazing...

Test

ANA, anti-LKM liver kidney microsome High transferrin saturation gt 50 , high ferritin HBeAg hepatitis B e antigen HBsAg hepatitis B surface antigen. HBeAg hepatitis B e antigen HBsAg hepatitis B surface antigen. in the 10 years following infection. Within 20 years, 30 of those will develop cirrhosis, and over 30 years, 30 of those with cirrhosis may develop hepatocellular carcinoma. Therapy is directed toward reducing the viral load to prevent the sequelae of end-stage cirrhosis, liver...

High Anion Gap Metabolic Acidosis

Renal failure acute or chronic Reproduced with permission from DuBoseTD. Acidosis and alkalosis. In Braunwald E. Fauci AS, Kasper KL. et al, eds. Harrison's principles of internal medicine. 16th ed. New York McGraw-Hill, 2005 265. alcoholism discussed later . The ingested toxins may be organic acids themselves, such as salicylic acid, or have acidic metabolites, such as formic acid from methanol. Renal failure leads to an inability to excrete organic acids as well as inorganic acids such as...

Common Causes Of Hematuria

Intrarenal Hematuria Kidney trauma Renal stones and crystals Glomerulonephritis Infection pyelonephritis Neoplasia renal cell carcinoma Vascular injury vasculitis, renal thrombosis Extrarenal Hematuria Trauma e.g., Foley placement Infections urethritis, prostatitis, cystitis Nephrolithiasis ureteral stones Neoplasia prostate, bladder imaging studies often are necessary, and considering the potential clinical implications, the etiology of hematuria should be pursued in all cases of hematuria....

Cases

A 58-year-old man presents to the emergency room complaining of severe pain in his left foot that woke him from sleep. He has a history of chronic stable angina, hypercholesterolemia, and hypertension, for which he takes aspirin, atenolol, and simvastatin. He has experienced pain in both calves and feet with walking for several years, and the pain has gradually progressed so that he can now only walk 100 feet before he has to stop because of pain. He occasionally has experienced mild pain in...

Complication Characteristics Treatment

Abscess Suspected in patients with Conservative management for a tender mass on small pericolic abscesses. CT- examination. persistent guided percutaneous drainage or fever and leukocytosis in surgical drainage for other spite of adequate therapy, abscesses depending 011 the size, or a suggestive finding on content, location, and peritoneal imaging studies. contamination. Fistulas Majority is colovesical with Single-stage surgery with fistula male predominance be- closure and primary...

Prothrombin Time

Normal to 5 mg dL 85 due to indirect fractions No bilirubinuria Acute hepatocellular necrosis viral and drug hepatitis, hepatotoxins. acute heart failure Both fractions may be elevated. Peak usually follows aminotransferases Bilirubinuria Elevated, often gt 500 IU L ALT gt AST Normal to lt 3 times normal elevation Usually normal gt 5X above control and not corrected by parenteral vitamin K, suggests poor prognosis Both fractions may be elevated Bilirubinuria Normal to lt 3 times normal...

Approach To Hyperthyroidism Definitions

Hyperthyroidism Hypermetabolic condition that results from the effect of excessive amounts of thyroid hormones produced by the thyroid gland itself. Because almost all cases of thyrotoxicosis are caused by thyroid overproduction, these terms are often used synonymously. Thyrotoxicosis Usually used as a general term for biochemical and physiologic manifestations of excessive levels of thyroid hormones from any source, for example, exogenous ingestion. Hyperthyroidism affects numerous body...

Answers To Case 17 Acute Renal Failure

Summary A 54-year-old diabetic male is receiving medical therapy consisting of oral aspirin, beta-blockers. ACE inhibitor, and intravenous nitroglycerin for treatment of his angina and hypertension. He undergoes coronary angiography, which reveals no significant stenosis. He is normotensive. His funduscopic examination shows dot hemorrhages and hard exudates, evidence of diabetic retinopathy. In this setting, the baseline elevated creatinine level on admission likely represents diabetic...

Answers To Case 40 Adrenal Insufficiency

Summary A 58-year-old woman presents with orthostatic hypotension, intermittent chronic abdominal pain, and constitutional symptoms such as fatigue and unintentional weight loss. She also has hyponatremia, hyperkalemia, acidosis. and hypoglycemia. All of this patient's clinical features are consistent with acute adrenal insufficiency. Although the most common cause of adrenal insufficiency is idiopathic autoimmune destruction, in her case, it may be due to adrenal metastases from breast cancer....

Blood Pressure Of 108

Pulmonary tuberculosis diagnosis and treatment. BMJ 2006 332 1194-197. Jasmer RM. Nahid P, Hopewell PC. Latent tuberculosis infection. N Engl J Med 2002 347 1860-1866. Raviglione MC. O'Brian R. Tuberculosis. In Kasper DL, Braunwald E, Fauci AS, et al, eds. Harrison's principles of internal medicine, 16th ed. New York McGraw-Hill, 2005 953-966. Small PM, Fujiwara PI. Management of tuberculosis in the United States. N Engl J Med 2001 345 189-200. A 42-year-old man...

Approach To Aortic Aneurysm And Dissection Definitions

Abdominal aortic aneurysm AAA Defined as a pathologic dilation to more than 1.5 times the normal diameter of the aorta. Aneurysms can occur anywhere in the thoracic or abdominal aorta, but the large majority occur in the abdomen, below the renal arteries. Aortic dissection dissecting hematoma Tear or ulceration of the aortic intima that allows pulsatile aortic flow to dissect longitudinally along elastic planes of the media, creating a false lumen or channel for blood flow. Sometimes referred...

Clinical Features

The clinical presentation depends on the relative deficiency of glucocorticoids and mineralocorticoids, ACTH excess, and other associated disorders. Acute adrenal insufficiency, or Addisonian crisis, may present with weakness, nausea, vomiting, abdominal pain, fever, hypotension, and tachycardia. Laboratory findings may include hyponatremia, hyperkalemia, metabolic acidosis, azotemia as a consequence of aldosterone deficiency, and hypoglycemia and eosinophilia as a consequence of Cortisol...

Churgstrauss

Algorithm approach to the patient with acute glomerulonephritis. ANA antinuclear antibody ANCA antineutrophil cytoplasmic antibody ASO antistreptolysin-O c-ANCA cytoplasmic antineutrophil cytoplasmic antibody GBM glomerular basement membrane HSP Henoch-Schonlein purpura MPGN membranoproliferative glomerulonephritis PAN periarteritis nodosa p-ANCA perinuclear antineutrophil cytoplasmic antibody SLE systemic lupus erythematosus. 119.1 An 18-year-old marathon runner has been training...

Causes Of Acute Pancreatitis

Biliary tract disease e.g gallstones Alcohol use Drugs e.g the antiretroviral didanosine ddl , pentamidine, thiazides, furosemide, sulfonamides, azathioprine, L-asparaginase Surgical manipulation of the gland or ERCP Infections such as mumps or cytomegalovirus Trauma such as blunt abdominal trauma Abdominal pain is the cardinal symptom of pancreatitis and often is severe, typically in the upper abdomen with radiation to the back. The pain often is relieved by sitting up and bending forward, and...

Definition

Deep venous thrombosis DVT Blood clot in the deep venous system that usually affects the lower extremities or pelvic veins. Clinical Approach Etiology and Risk Factors Successful treatment and management of PE requires a combination of clinical suspicion and appropriate use of diagnostic tools. Pulmonary emboli usually arise from deep venous thrombi and occasionally from less common sources, including air, fat. tumor, bone marrow, talc, amniotic fluid, arthroplasty cement, and sepsis. More than...

Approach To Suspected Pneumonia

Pneumonia is an infection of the lung parenchyma. Patients may present with any of a combination of cough, fever, pleuritic chest pain, sputum production, shortness of breath, hypoxia, and respiratory distress. Certain clinical presentations are associated with particular infectious agents. For example, the typical pneumonia is often described as having a sudden onset of fever, cough with productive sputum, often associated with pleuritic chest pain, and possibly rust-colored sputum. This is...

Answers To Case 18 Acute Pericarditis Caused by Systemic Lupus Erythematosus

Summary A young woman presents with nonexertional pleuritic chest pain that is relieved with sitting forward. In addition, she has a pericardial friction rub and ECG changes consistent with acute pericarditis. She has no radiographic evidence of a large pericardial effusion and no clinical signs of cardiac tamponade. Regarding the etiology of her pericarditis, she has pancytopenia and an active urinary sediment, which could be caused by infection but may also represent a connective tissue...

Approach To Acute Pericarditis

Acute pericarditis is an inflammation of the pericardial sac surrounding the heart. It can result from a multitude of disease processes, but the most common causes are listed in Table 18-1. There is a wide spectrum of clinical presentations, from subclinical or inap-parent inflammation, to the classic presentation of acute pericarditis with chest pain, to subacute or chronic inflammation, persisting weeks to months. Most patients with acute pericarditis seek medical attention because of chest...

Solitary Pulmonary Nodule

The solitary pulmonary nodule is defined as a nodule surrounded by normal parenchyma. Approximately 35 of solitary pulmonary nodules are malignant. Proper management of a solitary nodule in an individual patient depends on a variety of elements age, risk factors, presence of calcifications, and size of the nodule. The presence and type of calcification on a solitary pulmonary nodule can be helpful. Popcorn and bull's-eye calcifications suggest a benign process. In low-risk patients i.e age 35...

Approach To Suspected Hepatitis Viral Hepatitis

Most cases of acute hepatitis are caused by infection with one of five viruses hepatitis A. B. C, D, or E. They can produce virtually indistinguishable clinical syndromes, although it is unusual to observe acute hepatitis C. Affected individuals often complain of a prodrome of nonspecific constitutional symptoms, including fever, nausea, fatigue, arthralgias, myalgias, headache, and sometimes pharyngitis and coryza. This is followed by the onset of visible jaundice caused by hyperbilirubinemia,...

A 28yr Old Man Comes To Your Office Complaining Of 5 Day History Of Nausea

Endocrine hypertension. In Larsen PR. Kronenberg HM. Melnied S. Polonsky KS, eds. Williams' textbook of endocrinology, l th ed. Philadelphia. WB Saunders, 2003 555-562. O'Connor DT. The adrenal medulla, catecholamines, and pheochromocytoma. In Goldman L. Bennett JC. eds. Cecil's textbook of medicine, 21st ed. Philadelphia. WB Saunders. 2000 1259-1262. Pacak K. Linehan WM. Eisenhofer G, et al. Recent advances in the diagnosis, localisation. and treatment of...

Answers To Case 38 Hemoptysis Lung Cancer

Summary A 68-year-old female smoker has coughed up a cupful of bright red blood. For the previous 3-4 months, she has had a chronic nonproductive cough and. more recently, some blood-streaked sputum. She reports increase fatigability, reduced appetite, and unintentional weight loss. She denies chest pain, fever, chills, or night sweats. On examination, her chest reveals scattered rhonchi bilaterally without wheezes or crackles. She has clubbing of the fingers. Next step Chest x-ray film,...

Approach To Hypertensive Emergencies

Hypertensive crises are critical elevations in blood pressure, which usually are classified as either hypertensive emergencies or urgencies. The presence of acute end-organ damage constitutes a hypertensive emergency, whereas the absence of such complications is considered hypertensive urgency. Examples of acute end-organ damage include hypertensive encephalopathy, myocardial ischemia or infarction associated with markedly elevated blood pressure, aortic dissection, and pulmonary edema...

Gallstones

Gallstones usually form as a consequence of precipitation of cholesterol microcrystals in bile. They are very common, occurring in 10-20 of patients older than 65 years. Patients often are asymptomatic. When discovered incidentally, they can be followed without intervention, as only 10 of patients will develop any symptoms related to their stones within 10 years. When patients do develop symptoms because of a stone in the cystic duct or Hartmann pouch, the typical attack of biliary colic...

Approach To Suspected Meningitis

Bacterial meningitis is the most common pus-forming intracranial infection, with an incidence of 2.5 per lO.OOO persons. The microbiology of the disease has changed somewhat since the introduction of the Haemophilus influenza type B vaccine in the 1980s. Now Streptococcus pneumoniae is the most common bacterial isolate, with Neisseria meningitidis a close second. Group B streptococcus or Streptococcus agalactiae occurs in approximately 10 of cases, more frequently in neonates or in patients...

Management

Thromboangiitis Obliterans

The goals of therapy include reductions in cardiovascular morbidity and mortality. improvement in quality of life by decreasing symptoms of claudication and eliminating rest pain, and preservation of limb viability. The first step in managing patients with PAD is risk factor modification. Because of the likelihood of coexisting atherosclerotic vascular disease such as coronary artery disease, patients with symptomatic PAD have an estimated mortality rate of 50 in 10 years, most often as a...

Approach To Hypertension

Essential hypertension Also known as idiopathic or primary hypertension. It has no known cause, yet it comprises approximately 95 of all cases of hypertension. Lifestyle modification A cornerstone in the treatment of hypertension, consisting of regular aerobic activity, weight loss, decreased salt intake, and increased intake of fruit and vegetables, while decreasing the amount of total fat. especially saturated fat, in the diet. Alcohol consumption should be moderated, no more than two glasses...

Approach To Peptic Ulcer Disease Definitions

Dyspepsia Pain or discomfort centered in the upper abdomen mainly in or around the midline , which can be associated with fullness, early satiety, bloating, or nausea. Dyspepsia can be intermittent or continuous, and it may or may not be related to meals. Functional nonulcer dyspepsia Symptoms as described for dyspepsia, persisting for at least 12 weeks but without evidence of ulcer on endoscopy. Helicobacter pylori A gram-negative microaerophilic bacillus that resides within the mucus layer of...

Answers To Case 26 Acute Sigmoid Diverticulitis

Summary A 61-year-old man has 3 days of new-onset, worsening, left lower quadrant abdominal pain. He feels nauseated, and he has not had any bowel movements since the illness began. His temperature is 100.2 F and he has no pallor or jaundice. His abdomen is mildly distended with hypoactive active bowel sounds and marked left lower quadrant tenderness with voluntary guarding. Rectal examination reveals tenderness, and his stool is negative for occult blood. The WBC count is 11,800 mm3 with 74...

Stages Of Diverticulitis

Stage I Small, confined pericolic abscess Stage II Distant abscess retroperitoneal or pelvic Stage III Generalized suppurative peritonitis from rupture of abscess noncommu- nicating with bowel lumen Stage IV Fecal peritonitis caused by a free communicating perforation diverticular neck, setting up for more inflammation and diminished venous outflow, as well as bacterial overgrowth, which ultimately leads to abrasion and perforation of the thin diverticular wall. It is classified into four...

Causes Of Atrial Fibrillation

Inflammatory disease pericarditis, myocarditis Surgery post-bypass surgery, post-valvular surgery Medications theophylline, caffeine, digitalis Atherosclerotic coronary artery disease Rheumatic heart disease especially with mitral stenosis Thyrotoxicosis Congenital heart disease atrial septal defect. Ebstein anomaly Hypertensive heart disease Alcohol consumption holiday heart syndrome, alcoholic cardiomyopathy Pulmonary disease, especially pulmonary embolus Many patients with AF cannot be...

Answers To Case 29 Bacterial Meningitis

Summary A 20-year-old college student presents with a 3-day history of fever, headache, myalgias, and nausea. He has no respiratory or gastrointestinal symptoms, hut now has developed photophobia. He is febrile to I02.3 F. tachycardic. and normotensive. His physical examination is generally unremarkable with a nonlocal neurologic examination but some neck stiffness, suggesting meningeal irritation. He has no skin lesions as might be seen in meningococcemia. Condition most likely concern...

Answers To Case 13 Cirrhosis Probable Hepatitis C Related

Summary A 49-year-old woman presents with new-onset abdominal swelling. Her history reveals a blood transfusion with postpartum hemorrhage and cocaine use. On examination, her temperature is I00.3 F, heart rate 88 bpm, and blood pressure 94 60 mmHg. Her sclerae are icteric. Her abdomen is distended, with mild diffuse tenderness, shifting dullness to percussion, and a fluid wave, consistent with ascites. She has no peripheral edema. Laboratory studies show the following levels Na 129 mmol L,...

Selected Causes Of Congestive Heart Failure

Myocardial Injury Adriamycin Alcohol use Cocaine Ischemic cardiomyopathy atherosclerotic coronary artery disease Rheumatic fever Viral myocarditis Chronic Pressure Overload Aortic stenosis Hypertension Chronic Volume Overload Mitral regurgiation Infiltrative Diseases Amyloidosis Hemochromatosis sonic beta-blockers, such as carvedilol, metoprolol, or bisoprolol, have been shown to reduce mortality in patients with impaired systolic function and moderate to severe symptoms. In patients who cannot...

Causes Of Hyponatremia

Posttransurethral resection of prostate bladder tumor Primary Na loss secondary water gain 1. Integumentary loss sweating, burns 2. Gastrointestinal loss vomiting, tube drainage, fistula, obstruction, diarrhea 3. Renal loss diuretics, osmotic diuresis, hypoaldosleronism. salt-wasting nephropathy, postobstructive diuresis, nonoliguric acute tubular necrosis A. Primary water gain secondary Na loss 2. Decreased solute intake e.g beer potomania 3. AVP release as a result of pain, nausea, drugs...

Clinical Manifestation

Critical coronary artery sterosis gt 70 Unstable platelet thrombus on ruptured plaque Platelet thrombus begins to form and spasm limits blood tlow at rest Transient or incomplete vessel occlusion lysis occurs Non-ST elevation myocardial infarction Platelet thrombus on ruptured plaque Complete vessel occlusion no lysis There are no specific physical findings in a patient with an acute MI. Many patients are anxious and diaphoretic. Cardiac auscultation may reveal an S4 gallop, reflecting...

Serologic Markers Of Glomerulonephritis

C4 low in complement-mediated GN SLE. MPGN. infective endocarditis, poststreptococcal postinfectious GN, cryoglobulin-induced GN Antineutrophil cytoplasmic antibody levels p-ANCA and c-ANCA positive in Wegener, microscopic polyangiitis. Churg-Strauss ANA positive in SLE anti-dsDNA, anti-Smith Antiglomerular basement membrane anti-GBM antibody levels positive in anti-GBM GN and Goodpasture ASO titers elevated in poststreptococcal GN postinfectious GN Blood cultures positive...

115 92 Blood Pressure

Armstrong PE. ct al. ACC AHA guidelines for the management of patients with ST elevation myocardial infarction. Circulation 2004 110 588. Antman EM. Braimwald E. ST segment elevation myocardial infarction. In Kaspcr DL. Braunwald E, Fauci AS. et al., eds. Harrison's principles of internal medicine. 16th ed. New York McGraw-Hill. 2005 1434-1462. Kceley EC. Boura JA. Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction A...

Causes Of Syncope

Sinus bradycardia, sinoatrial block, sinus arrest, sick sinus syndrome a. Supraventricular tachycardia with structural cardiac disease b. Atrial fibrillation associated with the Wolff-Parkinson-White syndrome c. Atrial flutter with 1 1 atrioventricular conduction B. Other cardiopulmonary etiologies 4. Myocardial disease massive myocardial infarction 5. Left ventricular myocardial restriction or constriction 6. Pericardial constriction or tamponade 7. Aortic outflow tract obstruction aortic...

Contraindications To Thrombolytic Therapy

Major surgery trauma within past 2 weeks Active internal bleeding excluding menses History of cerebral tumor hemorrhage arteriovenous malformation Prolonged, traumatic cardiopulmonary resuscitation Allergy to agent prior reaction Cerebrovascular accident known to be hemorrhage within past 12 months History of uncontrolled hypertension Recent hepatic renal biopsy Blood pressure gt 180 110 mmHg on gt 2 readings Diabetic retinopathy with recent bleed Stroke transient ischemic attack within past...